American Psychological Association

119th Annual Convention
Washington D.C., August 4-7 2011

August 6, 2011 – Saturday
Washington, D.C.

First up today was a presentation that was strongly recommended by a respected colleague, an invited address by Kate Cavanagh, author of “Hands-on Help”, an acclaimed book Amazon called a “must read”, about online mental health programmes. (OK, U.S. spellcheck; “programs”.) She is from the UK, and began with a very warm note about her introduction to the scale of APA conferences and expressing the hope we’d understand her funny accent.. She was fine, and the only difficulties in fact were with the wireless connectivity in the room, ironically. Time flew and she apologized for not presenting more (including some online demos) but one hopes she will return (and perhaps we can scrape up a hard-wire connection). She encouraged interaction with this energized American audience of psychologists, and so many questions were asked. Yes it ate a bit of time but also was evidence of what a hot topic she was presenting and how many buttons were pushed by the many points she covered. “Well done you”.

The first of 2 parts was to be “setting the context” and an introduction to Computerized Cognitive Behavior Therapy. (To me, who has recently published “Context is everything”, I was thrilled to hear the attention to context.) The second part, time permitting, was to be on the dissemination of implementation of these programs.

After apologizing if her first dose of American (Starbucks) coffee sets her a-twitter, Dr. Cavanagh said she would like this to be interactive and wanted first, confronted with a large room full of a diverse collection of American psychologists, to “take the temperature”. How many in the room are predisposed positively towards the concept of computerized CBT programs? Many hands went up. Negative? Not one hand.

Noting that her usual context is UK health system utilization, she knew the statistics are quite similar in several dimensions to the American numbers. In the UK approximately 1 in 5 suffers from some sort of depression or anxiety. One third seek help. One in 10 Americans report depression with a total of 18% reporting depression, panic or GAD [global anxiety disorder] Thus the overview of US prevalence is very close to the UK’s. There are slightly more US residents who seek treatment. The perception in the UK is that “there just are not enough resources for those who might benefit” from some sort of treatment program. There is currently underway a huge government initiative in the UK - IAPT (Increasing Access to Psychological Therapies) which has a goal adding 3500 specialists in CBT and other evidence-based treatments for mild-to-moderate disorders, within the next four years.

Part of the solution is seen as derived from deployment of "Computerized Psychological Therapies", which offer a number of advantages and characteristics:

They offer structured programs with the opportunity to use patient input to make at least some treatment decisions

They are accessed via computing devices, usually through the Internet (PC, smartphone, IVR, Tablet/iPad)

They can be accessed within a healthcare practice or at home, supported and monitored by trained healthcare staff

The range of "guided self-help" definitions extends from around 1 hour of therapist time per week, to 5 hours with a coach/support worker. Typically there are brief, remote, weekly support sessions.

Generally there is a narrative or therapist plus a case study component.
There may be an additional email or real-time consultation component.

The context of British service delivery is that it includes prescription of evidence based treatments for some presenting problems, including CCBT. (Computerised Cognitive Behavioural Therapy)

The UK's NICE (National Institute for Clinical Excellence) has put a great deal of resources into researching and supporting the “Stepped-care model” - roughly in US terms the sort of list of approved procedures our insurers approve (or not) based on cost-benefit, efficacy, and safety factors. CCBT is a recommended treatment of choice for low intensity therapy for depression and anxiety – but not PTSD.

There is a long history of computer-assisted therapy activities, for example going back to the Eliza era where the technology allowed for “natural language” and the persona was that of a "humanistic therapist." In the 1970’s this was being undertaken using things like the Commodore 64 computer, pressing buttons for feedback.

By the 1990’s there was mounting evidence (Bloom, 1992) of efficacy, and moreover, that “graded exposure does not appear to require interaction with a therapist in order to be successful”. By 2000, Kirkby et al at the U. of Tasmania (Australia) were reporting promising results with their CAVE program (Computer-aided vicarious exposure) for obsessive-compulsive disorder.

At present, there is lots of use of avatars. You can manipulate facial expressions, settings, and individualized features. For example, in a virtual environment “I could have practiced this presentation today”.

One example of a popular application is Fear Fighter, an 8-session program to address panic and anxiety. There is a strong evidence base to support its efficacy. Another program with strong evidence supporting its efficacy is Beating the Blues. Dr. Cavanagh proceeded to give a demonstration: “The U.S. Debut!”.

The interface is very attractive and user-friendly [as you can see if you follow the link above], and today we were shown "the US version" - where the dialogue was in American as opposed to proper English but otherwise identical. One is greeted by some vignettes of people who might have familiar feelings: “I couldn’t cope”; “I have no energy”. Narrator: “One in five suffers from depression or anxiety… CBT breaks the cycle” There are several descriptions and vignettes and continues: “It teaches you the causes of anxiety and what you can do to overcome it. It can help you feel better even if you’re already on medication.” Eight sessions, once weekly.

The automated explanation for the new patient/client instructs him/her to choose a password to log in with, and then underscores that it is “really important” that the user completes their weekly project and carry out the activity since “research shows 3 times more benefit when doing the projects”. Next was “Bob’s story”, describing how the program “gave me the confidence to recognize my own feelings.” Another example: A woman was in a car crash and consequently avoided being in a car. Now [shot of her in car] she’s driving again. Another woman “I just feel a lot calmer”. “Get your first session now!” Another pitch or two (from the program) and Cavanagh paused to take the pulse again of the audience and elicit some feedback and reaction from the first American psychologists to see this.

Question: Who buys this? Who is the marketing aimed at?

Answer: In the UK primarily it is marketed to professionals. The patient may get a ‘scrip for this rather than for medication. So it is a case of getting it known and used.

Question: Is it free?

Answer: In the UK it is, for the user. We get our health treatment through the NHS (National Health Service). We pay for it through taxes.

Comment: This certainly is a slick production and well-marketed. Personally what I like about it is the built-in information-seeking component.

Comment/Question: – Yes, the video is very well done. It may be convincing to us. But what about lower SES clients? In rural areas access is not great. What about poor people?

Response: Poor people can’t have access?
In the UK services are made available, in community service settings.

Question: Is this treatment offered through primary care providers? I’m assuming they meet with a professional... is there any research on the importance of access to an actual provider?

Answer: There is limited research on these specific barriers. Clinical expertise locally generally addresses barriers.

Back to slides and the presentation

Beating the Blues, developed by Dr. Judy Proudfoot and Utrasis, was described a bit further, in terms of its many features which research has shown to be engaging and effective. It is a program several presenters this year - American as well as British, have cited. sited.

Beating the Blues is a program "designed for usability. It’s designed for people with limited computer skills". It too is an 8-week course. The first step is an introduction and overview meant to engage and inform the user. Included is a strong educational component such as built-in lessons about the nature of stress and ways to address it. The program is designed to address both cognitive and behavioral components in ways which are easily understandable. Session summaries, homework projects ("really important") and progress reports are all built-in to the program. (One example of a homework project which was shown: "Look for evidence against your inner belief"; another was "record reasons for successes") In the final module there is a session devoted to action planning and relapse prevention.

Session 1 - Demonstrated on the screen: the interface ("designed by a multi-professional team" and developed over a four year period).

There are 5 buttons with faces – each has a vignette such as the ones sampled earlier. One might start with this “psychoeducation” activity. There are case examples involving warmth and genuineness too (Rogers’ humanistic factors). And there are progress graphs and charts.

Next we were shown a number of research studies which yielded strong findings, so much so that the National Institute for Health and Clinical Excellence and NHS had to take notice (particularly given the Stepped-care mandate) and accept the evidence in support of CCBT.
It is now listed as a Step 2, "low-intensity psycho-social intervention" [One of the characters in a CCBT module, incidentally, was shown saying something to the effect of "by the way,even if you are taking medication already, you may still benefit from this program."]

The 2004 Proudfoot et.al. study (Journal of British Psychiatry) used Beck’s Depression and Anxiety scales as pretest and outcome measures - along with Health Service usage. There were 276 Subjects. Post-treatment results included evidence of “increased self-efficacy, mastery, coping, and ‘learned resourcefulness’. [Intrigued by the latter term, later this very day, by twist of fate, I had the chance to ask the legendary Martin Seligman- of 'learned helplessness' fame, if he was involved with or knew of ‘learned resourcefulness’. He recalled a popular paper of some 30 years ago. Obscure, he said, but an interesting concept! ]

Given the results, there was a determination that the cost effectiveness/benefits were potentially very great due not only to the cost and efficacy of treatment but also to mitigation of problems such as lost employment. Dr. Cavanagh and colleagues completed similar studies with large Subject groups (e.g, Cavanagh et al, 2007, with 510 participants). Consistently, Beating the Blues was found to be an effective tool for treatment of depression as part of routine primary care. "It doesn't just work,"Cavanagh found, "but clients generally have have a positive experience" to the extent that 90% found the treatment either helpful or very helpful, and 80% said they would recommend it. In Cavanagh et al's (2009, Cognitive Behavioural Therapy) study, only one person said the program was not at all helpful.

Proudfoot and Cavanagh were joined by many other researchers in researching the efficacy of this program. Cavanagh's popular book (Hands-on Help) included a systematic review of 175 studies, and again, the evidence was persuasive. It should be noted that a study by Cavanagh and colleagues in 2007 found efficacy in the treatment of a wide range of presenting problems, beyond depression.

Azy Barak also conducted a broad meta-analysis which was consistent with Cavanagh's findings.

One last study was mentioned: the recent and oft-cited study by Cuijpers et al (Clinical Psychology Review, 2010) which found no difference (within their own study) between guided and self-administered CCBT programs.

Some positive CCBT factors were reviewed. For example, there is an increased range of choices. The program provides more flexibility and increased confidentiality. The computer "hasn't had a bad day". The responses are absolutely consistent. The program doesn't decide on a hunch to switch gears and try a new approach not done before. Users report an increased sense of self-efficacy ("learned resourcefulness" as they master tasks and situations while also learning strategies and useful information.

And here, amid the many positives, Cavanagh paused to underscore that no matter how "evangelical" she may seem to be about this particular treatment protocol, she is "also a scientist" and there is simply overwhelming evidence now which cannot be ignored.

Some limitations were in fact noted too, such as "technophobia" which negates the value of the tool within 'the shiny box'. Similarly there is the issue of 'inaccessibility' - not in the sense of the program or online access not being available (as referenced by an earlier question, above) but where, for example, someone has an inability to read. Some see limitations in the formulations and solutions the program offers, some see the consistency as a negative rather than positive, while still others have difficulty meeting expectations, accepting credibility, or sustaining motivation without a greater level of support.

Summing up:

New ways of working are required to meet the unmet needs of many people suffering from anxiety and depression who could benefit from evidence based interventions

There is a growing evidence base that CCBT can help many people with common mental health problems

In the UK the National Institute for Health and Clinical Excellence recommends supported CCBT as a treatment option for depression, panic, phobias, and GAD

--

Another round of audience Q & A ensued, where some provocative questions were posed.

QU: What about use of this program in combination with 1:1 therapy?
Answer: "There is some evidence of increased efficacy with some provider contact, but it depends on the program."

There are a great many computer-assisted psychotherapyprograms out there, including also the well-researched Good Days Ahead "interactive program for depression and anxiety" produced and written by Jesse H. Wright, co-written by Andrew S. Wright and Aaron T. Beck. While designed to be "50-50" - self-help plus used in conjunction with a professional clinician - research has shown similar results comparing 50-50 use with computer-only (home) use. A third option exists too, which would be to use the program to sustain skills learned in treatment, after therapy sessions end.

With so many possibilities still, "lots more research needs to be done."

QU- This has been very impressive. One concern, possibly, about depression. Is there any way to alert someone who appears to be at high risk?

A: Contingency planning is generally "managed with local protocols." Some programs include self-management procedures, others have more interactive monitoring processing. Beating the Blues has a built-in suicide indicator which triggers a prompt to call one's provider.

QU: From a development point of view, is there not perhaps an over-reliance on video? I find it can be (1) costly; and (2) limiting in terms of all the creative animation - for example ensuring representation of diverse people and so forth. It doesn't seem to add anything.

A: "You're right. At one end we have stark programs; at the other end there are lots of 'bells and whistles'. What is the best combination?"

QU: Contextual question: The world gets smaller and smaller. We have more and more reliance on computers. The next generations will be the users [of these programs]... I watch people with over-reliance on computers, devices, tablets, all day... Could it hinder 'people skills' given that people are already spending their entire days on computers?

A: I share some of your concerns about that. We're looking at that, and seeing some interesting findings. For example, people with more avoidant presentations may be drawn to a purely self-administered program... I'm not convinced a Utopian world would be 100% computerized treatments.

QU: There is also an impressive resource in Australia - anxietyonline.org.au- which offers programs tailored to OCD, phobias, weight control, eating disorders... [See too the Australia-based Beaconportal for a comprehensive listing of online applications - for computer and now mobile devices as well, organized and rated by a panel of health experts.]

Dr. Cavanagh has clearly engaged this audience and gotten her wish - to take the pulse of this APA audience while delivering this dense and fascinating presentation. But time has flown and time is nearly up. Would the audience like to see more demonstrations? Clearly yes. And so there was just a brief introduction to Part 2 - now turning from guided self-help programs to "pure" self help CCBT programs on the Internet where no human support is offered at all. In general there is a weaker evidence base with regard to clinical outcomes.

So what is known about completely self-administered CCBT programs?

On the plus side, "there is some evidence that 'pure' self-help can be beneficial for some users." Moreover, fully automated interventions extend reach and reduce expenditure of resources. However, "low return visit rates are found in casual visitors to unmoderated CCBT programs." In contrast, guided self-help programs (where the user has access to both the CCBT program and a therapist/coach) there is some evidence of effectiveness for both anxiety and depression, higher return visit rates, and a 68% completion rate, reported in one study (Kaltenthaler et al).

---

Unfortunately, before getting further into demonstrations, time had completely expired on today's presentation. Yet, quite a lot had indeed been presented, and surely the audience had seen and learned quite a bit - while offering up a great deal of reaction and feedback as to the reactions and concerns of mostly-American psychologists.

The discussions go on, along with the burgeoning of new research and practice directions.